Authorization

Authorization

Moving Forward, PLC — Michele T. Cole, Ph.D., LCSW, 117 S. St. Asaph St., Alexandria, VA 22314, 571-483-0306
I authorize and give permission to Moving Forward PLC to keep my signature on file and charge my Visa, Mastercard, American Express, Discover, or other prefered payment card/method for all psychotherapy related charges associated with my account. My card details will be stored in my profile, and charged on the next business day.
The following payment options are in place to keep your credit card information secure. ***Please note that credit card information must be collected prior to your scheduled session.*

1. I would like someone on the support team to contact me directly for payment details to ensure the safety of my credit card information. ***Please make sure you are available as this should be collected prior to your session.2. Leave a voicemail with payment information on our secure confidential voicemail by reaching: 571-483-0306. ***Please leave prior to session.3. Other (please fill in the blank field below)
Other (please specify):
Date of Intake Session*

MonthDayYear
Date
Patient Name*

First NameLast Name
Cardholder Name

First NameLast Name
Cardholder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cardholder Phone Number*
Please enter a valid phone number.
Cardholder Email*
example@example.com
Effective Date*

MonthDayYear
Date
Cardholder Signature*

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If you would like to contact us directly please email us at: adminsupport@movingforwardplc.com

Thank you!
Please verify that you are human*
Thank You,
Michele T. Cole, Ph.D., LCSW
Director, Moving Forward, PLC
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